Inquest into death of 29-year-old man finds failings by Cygnet Healthcare contributed to his death on St Austell railway
Posted on: 20th June 2016
Today, a jury at the inquest into the death of David Knight, a 29-year-old man from St Austell in Cornwall, has found that failings in risk assessments and communication with David’s local treatment team were inadequate and contributed to David’s death.
Mr Knight had been suffering from paranoid schizophrenia for a number of years and had previously attempted to commit suicide on the railway near his home. Prior to his death he had been sectioned under the Mental Health Act due to a deterioration in his psychiatric condition and was admitted to Cygnet Hospital Kewstoke in Weston Super Mare, due to no psychiatric beds being available in Cornwall. David remained there as a patient for eight weeks, as a bed nearer home was not found for him.
Despite experiencing a relapse in symptoms only the previous week and concerns from his family that he was unwell and not being suitably medicated, he was released on home leave on 21 May 2015. His local home treatment team were not notified and therefore, did not provide any support during his home leave
Two days later on 23 May, Mr Knight took his own life by standing in front of a train on the St Austell viaduct near his home, the same place he had previously attempted suicide.
Dawn Treloar says: “David’s family are devastated by his loss and are shocked by the catalogue of failings by those who were treating him. His mother knew her son was extremely unwell and had feared for his safety on a number of occasions, expressing her concerns to healthcare staff that he was deteriorating and would benefit from a different form of medication, this having been advocated by his local treating Consultant. Her concerns were ignored, and David was sent on home leave when he was unwell and without adequate support.
“The jury concluded that David’s death was caused by suicide, and that inadequate risk assessment and inadequate communication with the home treatment team more than minimally contributed to the death. They also concluded that failure to engage with mental health services and cannabis use were contributing factors.
“We hope that lessons will be learned from David’s case and that Cygnet Healthcare will take steps to prevent future deaths by better communicating with the treating community psychiatrists when patients are being treated outside of their usual county, as well as improving risk assessment of patients and improving communication with their loved ones.” Significant changes are required if vulnerable patients are to receive the standard of care they need and to protect them from harm.”
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